A Schatzki ring, also called a Schatzki-Gary ring, is a symptomatic, narrow esophageal B-ring occurring in the distal esophagus and usually associated with a hiatus hernia.
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Epidemiology
Relatively common, lower esophageal rings are found in ~6-14% of oesophagrams 9.
Associations
More than half of patients will have an associated esophageal condition such as 2:
Clinical presentation
Most commonly, it presents as intermittent dysphagia, especially to solid food. A history of food impaction is also very common. Dysphagia is more common in patients with an associated motility disorder.
Pathology
The pathogenesis of the Schatzki ring is unclear with conflicting hypotheses that include redundant pleats of mucosa, congenital abnormalities and modified peptic strictures. Interestingly, there is a reduced incidence of Barrett esophagus in patients with a Schatzki ring.
Depending on its luminal diameter, an esophageal B-ring may be symptomatic or asymptomatic 4:
<13 mm: almost always symptomatic
13-20 mm: sometimes symptomatic
>20 mm: rarely symptomatic
When it is symptomatic, it is termed a "Schatzki ring" ref.
Location
Schatzki rings are located at the gastro-esophageal junction, illustrated by the fact that there is squamous epithelium above and columnar epithelial below the ring. They should not be confused with
A-rings, which are found a few centimeters proximal to the B-ring
esophageal webs, which are lined on both sides by esophageal mucosa 6-8
Radiographic features
Fluoroscopy
Barium swallow
Single-contrast barium swallows (especially in the RAO prone position) are more sensitive than endoscopy in detecting Schatzki rings 3. On barium swallow the following features may be seen 1:
full-column barium swallow will reveal a circumferential narrowing at the gastro-esophageal junction, often a few centimeters above the diaphragmatic hiatus
thin smooth ring, 1-3 mm
Sensitivity can be improved by:
performing a Valsalva maneuver
using barium tablet or barium-coated marshmallow
Double-contrast barium studies are less sensitive
Treatment and prognosis
Treatment of Schatzki ring is done with four-quadrant biopsy, bougies or pneumatic balloon dilatation 9.
History and etymology
Schatzki rings are named after Richard Schatzki (1901-92), an American physician, who was born in Germany 1. His co-author on his article introducing his eponymous ring was John E Gary (1916-1970), a radiology colleague at Mount Auburn Hospital in Cambridge, Massachusetts, hence its occasional moniker, a Schatzki-Gary ring 10.
Differential diagnosis
On fluoroscopy consider
ringlike peptic stricture: the indentations are fixed, asymmetric, and wider than those seen in a mucosal B ring
distal esophageal carcinoma: usually irregular in appearance
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